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CRISIS AND EMERGENCY

RISK COMMUNICATION

Pandemic Inuenza

August 2006

Revised October 2007


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The purpose of this book is to provide the reader with vital communication concepts and tools to assist in

preparing for and responding to a severe inuenza pandemic in the United States. The focus of the book

is on the possibility of a severe pandemic. Although the concepts do apply to less intense public health

challenges, they may not need to be executed at the same level of intensity.

This book is intended to be used as an addition to the CDC Crisis and Emergency Risk Communication

coursebook (Reynolds, Galdo, Sokler, 2002) and the Crisis and Emergency Risk Communication: By

Leaders for Leaders coursebook (Reynolds, 2004). The concepts in this book do not replace, but, instead, build on the rst two books. This book shares foundational concepts that will support your communication

work and should be relevant even as the circumstances surrounding a severe pandemic may change.

Nonetheless, the information in this book is current as of October 2007. As major events occur, especially

related to countermeasures such as pandemic vaccine development, some assumptions may change.

Importantly, this book explains in more depth the communication challenges to be expected in a severe

inuenza pandemic. This is not a primer on pandemic inuenza and is not the place to turn to for up-to-date

message maps, communication tools, and pandemic preparedness and planning information. The “go-to”

place for evolving information is the U. S. Government Pandemic Flu website at http://www.pandemicu.

gov. At www.pandemicu.gov you will nd resource materials for creating communication products, as well

as additional guidance on planning. HHS and CDC are engaged in a number of research and development projects related to pandemic communication. Check the website regularly for updates.

CDC • Crisis and Emergency Risk Communicationii


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Crisis and Emergency Risk Communication:

Pandemic Inuenza

Made possible by

U.S. Department of Health and Human Services (HHS)

In partnership with:

Centers for Disease Control and Prevention (CDC)

Ofce of the Director, Ofce of Enterprise Communication (OEC)

Coordinating Ofce of Health Information Services, National Center for Health Marketing

Written by

Barbara Reynolds, M.A,

Centers for Disease Control and Prevention

In collaboration with:

Shana Deitch, M.P.H. & Richard Schieber, M.D., M.P.H., Capt. USPHS

Centers for Disease Control and Prevention

Edited by:

Suzy DeFrancis, Assistant Secretary for Public Affairs (ASPA), HHS

Donna Garland, OEC, CDC

William Hall, ASPA, HHS

Shaunette Crawford, OEC, CDC

Ann Norwood, M.D., Ofce of Public Health Emergency Preparedness (OPHEP), HHS

Stephanie Marshall, ASPA, HHS

Sharon KD Hoskins, M.P.H., OEC, CDC

Lorine Spencer, B.S.N., M.B.A.,OD, CDC

Faculty

Barbara Reynolds, M.A., CDC

Matthew Seeger, Ph.D., Wayne State University

Tim Sellnow, Ph.D., North Dakota State University

Richard Brundage, President & CEO, Center for Advanced Media Studies

Robert Ulmer, Ph.D., University of Arkansas, Little Rock

Deanna Sellnow, Ph.D., North Dakota State University

Development, preparation, and implementation of this course were made possible through the knowledge, wisdom, and

effort of the people listed here:

CDCDan Baden, M.D. Annise Chung Benjamin Haynes Cecilia, Meijer Khalid Rodrigue

Jay Bernhardt, Ph.D. Lateka Dammond Sharon K.D. Hoskins Jennifer Morcone Marian Sachs

Mindy Barringer Irene Edward-Chery Jamila Howard Joshua Mott, Ph.D. Kristine Sheedy

Martha Boyd Ron Ergle Asim Jani Teresa Nastoff Lorine Spencer

Richard Bright Melinda Frost Mattie Jones Karen Ngowe Patricia Taliaferr

Mary Bryant-Mason Nancy Gathany William Jones III John O’Connor Lisa Williams

Alyce Burton Cynthia Goldsmith Ronald Lake Dori Reissman, M.D. Andrea Young

Emily Cramer D’Angela Green Cynthia Lewis Karen Resha James Archer

Bridget Cleveland Kathryn Harben Renee Maciejewski Matthew Reynolds

CDC • Crisis and Emergency Risk Communication ii


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Local and State Public Health Departments

Bart Aronoff, Hawaii Dept. of Health

Bret Atkins, Ohio Dept. of Health

Nancy Bourgeois, Los Angeles Dept. of Health and Human Services

Kim Coleman, West Virginia Dept. of Health and Human Resources

Debbie Crane, North Carolina Dept. of Health and Human Services

Nancy Erickson, Vermont Dept. of HealthLaura Espino, NPHIC

Jami Haberi, Iowa Dept. of Health

Larry Hill, Virginia Dept. of Health

Clara Jenkins, NPHIC

Richard McGarvey, Pennsylvania Dept. of Health

Christine Newlon, Nebraska Dept. of Health

Sandra Page-Cook, New York City Dept. of Health and Mental Hygiene

Marisa Raphael, New York City Dept. of Health and Mental Hygiene

Ken Seawright, Mississippi Dept. of Health

Doug Skroback, South Carolina Dept. of Health and Environmental Control

Tom Slater, New Jersey Dept. of Health and Senior ServicesSteve Wagner, Ohio Dept. of Health

Rhonda White, Florida Dept. of Health

Ann Wright, Arkansas Dept. of Health

CERC Consultation Panel

Laura Blaske (Washington state) Barbara Beiser (Colorado) Thomas Slater (New Jersey)

Jim Beasley (South Carolina) Marie Milkovich (Michigan) Nicola Whitley (New Hampshire)

Debbie Crane (North Carolina) Christine Holmgren (Oregon)

Kristine Smith (New York) Bret Atkins (Ohio)

Department of Health and Human Services

Jack Kalavritinos Thomas Harris, Region III Joe Nunez, Region, Region VIIIEric Jewett Chris Downing, Region IV Michelle McGowan, Region VIIILaura Caliguiri Deric Gilliard, Region IV Claise Munoz, Region IX By Region Dough O’Brien, Region V Jennifer Koentop, Region IXBrian Cresta. Region I Don Perkins, Region VI James Whiteld, Region XDavid Abdobo, Region I Ashlea Quinonez, Region VI Jenny Holladay, Region XDeborah Knopko, Region II Fred Schuster, Region VII

Gordon Woodrow, Region III Adele Hugley, Region VII

DoD

Lori Geckle, U.S. Army

Walter H. Orthner, Joint Forces

CommandDavid, A. Zacharias, Joint

Forces Command

Community & University

Dorothy Sorensen Claudia Parvanta, Ph.D. William Reynolds

Rita Cox Elizabeth Andrea Prebles National Archives

Alita Corbett Elizabeth Schatzel

With special thanks to Kim and the Village of Cedar Rapids

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Crisis and Emergency Risk Communication

Pandemic Inuenza

Table of Contents

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Checklist: Basic Tenets of Emergency Risk Communication . . . . . . . . . . . . 15

Checklist: Scientic Risk Communication for the Public . . . . . . . . . . . . . . . 16

Severe Inuenza Pandemic: What is Different . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Biopsychosocial Challenges in the United States in a Severe Pandemic . . .40

Pandemic Inuenza: Stages of Federal Government Response. . . . . . . . . . .46

Community Hardiness and Personal Resilience . . . . . . . . . . . . . . . . . . . . . . . . .49

Checklist: Communication for Personal Resilience . . . . . . . . . . . . . . . . . . .64

Checklist: Communication for Community Hardiness . . . . . . . . . . . . . . . . .65

Topline Assessment of Community Hardiness by Selected Domains . . . . . .66

The Stigma of Pandemic Inuenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

Checklist: Inhibiting and Countering Stigmatization . . . . . . . . . . . . . . . . . . 83

Reaching Special Populations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87

Special Populations Assessment Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100

Best Practices: Customer Communication at the POD . . . . . . . . . . . . . . . .104

Understanding Loss, Grief, and Cultural Bereavement Rituals . . . . . . . . . . . .107

Checklist: Planning a Community-Wide Memorial Service . . . . . . . . . . . . 124

Information Technology in Pandemic Inuenza Communications. . . . . . . . . . 133

Evaluating Health Information on the Web . . . . . . . . . . . . . . . . . . . . . . . . . 146

Understanding the Role of NIMS/ICS for Pandemic Inuenza . . . . . . . . . . . .153 Authored by Richard Schieber, MD, MPH, National Immunization Program, CDC

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Introduction

Crisis and Emergency-Risk

Communication

Be rst. Be right. Be credible.

risk (rĭsk)n.

1. The possibility of suffering a harmful event.

2. A factor or course involving uncertain danger.

Crisis and emergency risk communication is a vital component of

public health emergency response. The initial objectives for public

information releases from response authorities early in a crisis are: 1) to

prevent further illness, injury, or death; 2) to restore or maintain calm;

and 3) to engender condence in the operational response (National

Response Plan, 2005). Because emergencies are chaotic, planning

should be directed at simplifying roles and responsibilities to achieve

the greatest good for the greatest number while maintaining enough

resources to reach those few who can’t help themselves (Clarke, 2003;

Seeger, Sellnow, & Ulmer, 2003).

Mitroff said about preparing for crises, “We must improve dramatically

our abilities to ‘think about the unthinkable’’’ (2004, p. 11). Among

these crises, the one most likely to directly involve the greatest number

of persons in the United States is a major respiratory-transmitted

infectious disease outbreak such as pandemic inuenza. In this

widespread emergency, public health response ofcials would need

to communicate messages to the public asking them to take particular

actions and refrain from other actions (e.g., engage in cough etiquette

and refrain from gathering in groups). An inuenza pandemic of a

highly pathogenic strain that occurs in our technologically advanced

society—where instant horizontal communication takes place around

the clock—will severely tax the ability of public health crisis response

ofcials to provide accurate, timely, consistent, and credible information

to the U.S. population (Reynolds et al., 2002). Emergency messages

will need to be communicated to a highly diverse U.S. population and to

cultures around the world.

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Introduction

Fast Facts

Four different inuenza

antiviral medications:

Amantadine,Rimantadine,

Oseltamivir, and

Zanamivir are approved

by the FDA for the

treatment and/or

prevention of inuenza.

All four antiviral

medications usuallywork against inuenza

A viruses. However, the

drugs may not always

work, because inuenza

virus strains can become

resistant to one or more

of these medications.

The inuenza A (H5N1)viruses identied in

humans in Asia in 2004

and 2005 have been

resistant to

Amantadine and

Rimantadine.

Monitoring of avian

viruses for resistanceto inuenza antiviral

medications continues.(www.pandemicu.gov)

According to the National Strategy for Pandemic Inuenza (2005), a

pandemic may come and go in waves, each of which can last for six to

eight weeks. An especially severe inuenza pandemic could lead to high

levels of illness, death, social disruption, and economic loss. Everyday

life would be disrupted because so many people in so many places

could become seriously ill at the same time. Impacts can range fromschool and business closings to the interruption of basic services such as

public transportation and food delivery. A substantial percentage of the

world’s population will require some form of medical care. Health care

facilities could be overwhelmed, creating a shortage of hospital staff,

beds, ventilators and other supplies. Surge capacity at non-traditional

sites such as schools may need to be created to cope with demand. The

need for vaccine is likely to outstrip supply and the supply of antiviral

drugs is also likely to be inadequate early in a pandemic. Difcult

decisions will need to be made regarding who gets antiviral drugs and

vaccines.

Death rates are determined by four factors: the number of people

who become infected; the virulence of the virus; the underlying

characteristics and vulnerability of affected populations; and the

availability and effectiveness of preventive measures. In the United

States alone, estimates of deaths during a pandemic range from

approximately 200,000 to 2 million (HHS, 2005). However, the effects

of a pandemic can be lessened if preparations are made ahead of time.

The following are assumptions that have been made by subject matter

experts to assist in planning for the next pandemic:

•

Susceptibility to the pandemic inuenza virus will be universal.

• Efcient and sustained person-to-person transmission signals animminent pandemic.

• The clinical disease attack rate will likely be 30% or higher

in the overall population during the pandemic. Illness rates

will be highest among school-aged children (about 40%) and

decline with age. Among working adults, an average of 20% wil

become ill during a community outbreak.

•

Some persons will become infected but not develop clinically

signicant symptoms. Asymptomatic or minimally symptomatic

individuals can transmit infection and develop immunity to

subsequent infection.

• Of those who become ill with inuenza, 50% will seek

outpatient medical care.

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Introduction

• Due to the availability of effective antiviral drugs for treatment,

the proportion of sick people seeking outpatient care may be

higher.

• The number of hospitalizations and deaths will depend on

the virulence of the pandemic virus. Estimates differ ten-fold between more and less severe scenarios. Two scenarios are

presented based on extrapolation of past pandemic experience

(Table 1). Planning should include the more severe scenario.

• Risk groups for severe and fatal infection cannot be predicted

with certainty but are likely to include infants, the elderly,

pregnant women, and persons with chronic medical conditions.

• Rates of absenteeism will depend on the severity of the pandemic.

• In a severe pandemic, absenteeism attributable to illness, the

need to care for ill family members, and fear of infection may

reach 40% during the peak weeks of a community outbreak,

with lower rates of absenteeism during the weeks before and

after the peak.

• Certain public health measures (dismissing students fromschool, quarantining household contacts of infected individuals,

“snow days”) are likely to increase rates of absenteeism.

•

The typical incubation period (interval between infection and

onset of symptoms) for inuenza is approximately 2 days.

• Persons who become ill may shed virus and can transmitinfection for up to one day before the onset of illness. Viral

shedding and the risk of transmission will be greatest during the

rst 2 days of illness. Children usually shed the greatest amount

of virus and therefore are likely to pose the greatest risk for

transmission.

•

On average, infected persons will transmit infection toapproximately two other people.

• In an affected community, a pandemic outbreak will last about 6to 8 weeks.

• Multiple waves (periods during which community outbreaks

occur across the country) of illness could occur with each wave

lasting 2-3 months.



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Characteristic Moderate 1958/68-like) Severe 1918-like)

Introduction

• Historically, the largest waves have occurred in the fall andwinter, but the seasonality of a pandemic cannot be predicted

with certainty.

Table 1. Number of Episodes of Illness, Healthcare Utilization, and

Death Associated with Moderate and Severe Pandemic InuenzaScenarios*

Characteristic Moderate (1958/68-like) Severe (1918-like)

Illness

Outpatient medical care

Hospitalization

ICU care

Mechanical ventilation

Deaths

90 million (30%)

45 million (50%)

865,000

128,750

64,875

209,000

90 million (30%)

45 million (50%)

9,900,000

1,485,000

745,500

1,903,000

* Estimates based on extrapolation from past pandemics in the United States. Note tha

these estimates do not include the potential impact of interventions not available dur

ing the 20th century pandemics.

Source: United States Department of Health and Human Services Pandemic Inuenza

Plan

Disasters are inherently different from routine daily emergencies and

the difference is more than just one of magnitude. Chaos theory relatedto crises emphasized that disasters that take a toll on human life are

inherently characterized by change, high levels of uncertainty, and

interactive complexity (Seeger, Sellnow, & Ulmer, 2003).

The possibilities of harmful human behaviors, combined with bad

communication practices, can lead to overwhelming negative public

health outcomes during the crisis response (Reynolds, Galdo, & Sokler,

2002; Seeger et al., 2003). However, many of the expected harmful

individual and community behaviors can be mitigated with effective

crisis and emergency risk communication. Strategic communications

activities based on scientically derived risk communications principlesare an integral part of a comprehensive public health response before,

during, and after an inuenza pandemic. Effective communication can

guide the public, the news media, healthcare providers, and other groups

in responding appropriately to outbreak situations and complying with

public health measures (HHS Pandemic Inuenza Plan).

Communications preparedness for an inuenza pandemic should follow

key risk communications concepts.



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Introduction

• When health risks are uncertain, as likely will be the case duringan inuenza pandemic, people need information about what is

known and unknown, as well as interim guidance to formulate

decisions to help protect their health and the health of others.

•

Coordination of message development and release ofinformation among federal, state, and local health ofcials is

critical to help avoid confusion that can undermine public trust,

raise fear and anxiety, and impede response measures.

• Guidance to community members about how to protect

themselves and their family members and colleagues is an

essential component of crisis management.

• Information provided to the public should be technically correct

and succinct without seeming patronizing.

• Information presented during an inuenza pandemic shouldminimize speculation and avoid over-interpretation of data and

avoid overly condent assessments of investigations and control

measures.

• An inuenza pandemic will generate immediate, intense, and

sustained demand for information from the public, healthcare

providers, policy makers, and news media. Healthcare workers

and public health staff are likely to be involved in media

relations and public health communications.

• Timely and transparent dissemination of accurate, science-based

information about pandemic inuenza and the progress of the

response can build public trust and condence.

To avoid confusion early in a crisis, accurate, relevant, simple, fast

and consistent messages are best (Reynolds et al., 2002; Seeger et al.,

2003). Communication expertise that supports the needs of public

health professionals responding to a public health emergency or crisis

will borrow from many areas of communication study. This special

combination is called “crisis and emergency risk communication.”

Crisis and emergency risk communication encompasses the urgency

of disaster communication with the need to communicate risks and

benets to stakeholders and the public (Reynolds et al., 2002; Reynolds

& Seeger, 2005). Crisis and emergency risk communication differs

from crisis communication in that the communicator is not perceived

as a participant in the crisis or disaster, except as an agent to resolve

the crisis or emergency. Crisis and emergency risk communication is

To avoid confusion,

accurate, relevant,

simple, fast, and

consistent messages

are best.



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Introduction

Crisis and emergency

risk communication is

the effort by experts to

provide information to

help people make thebest possible decisions

about their well-being

within nearly impossible

time constraints and

ultimately to accept

the imperfect nature of

choices during the crisis.

the effort by experts to provide information to allow an individual,

stakeholder, or an entire community to make the best possible decisions

about their well-being within nearly impossible time constraints and

help people ultimately to accept the imperfect nature of choices during

the crisis. This is the communication that goes on in emergency rooms,

not doctors’ ofces.

Crisis and emergency risk communication also differs from risk

communication in that a decision must be made within a narrow time

constraint, the decision may be irreversible, the outcome of the decision

may be uncertain, and the decision may need to be made with imperfect

or incomplete information. Crisis and emergency risk communication

represents an expert opinion provided in the hope that it benets its

receivers and advances a behavior or an action that allows for rapid and

efcient recovery from the event.

Crisis Communication Lifecycle

Understanding the communication pattern of a crisis can help

professionals anticipate problems and respond effectively. For

communication professionals, it’s vital to know that every emergency,

disaster, or crisis evolves in phases and that the communication must

evolve in tandem (Reynolds et al., 2002). By dividing the crisis into

phases, the communicator can anticipate the information needs of the

media, stakeholders, and the general public. Each phase has unique

informational requirements and the movement through each of the

phases will vary according to the triggering event (Figure 1). Not allcrises are created equally (Mitroff, 2004). The degree or intensity and

longevity of a crisis will impact required resources and staff needed to

provide risk information.

Pre-crisis phase

The pre-crisis phase is where all of the planning and most of the work

should be done. In this phase, organizations should consider the types

of disasters that they may need to address. Reasonable questions

can be anticipated, and preliminary answers can be sought. Initial

communication can be drafted with blanks to be lled in later. Alliances

and partnerships can be fostered to ensure that experts are speaking with

one voice.

Initial phase

In the initial phase of a crisis or emergency, people want information.

They want timely and accurate facts about what happened, and

where, and what is being done, and they want it now. They will



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Introduction

question the magnitude of the crisis, the immediacy of the threat to

them, the duration of the threat, and who is going to x the problem.

Communicators should be prepared to answer these questions as

quickly, accurately, and fully as possible.

Simplicity, credibility, veriability, consistency, and speed count whencommunicating in the initial phases of an emergency. The initial phase

of a crisis is characterized by confusion and intense media interest.

Information is usually incomplete, and facts are dispersed. It’s important

to recognize that information from the media, other organizations,

and even within one’s own organization may not be accurate. In the

initial phase of a crisis, there is no second chance to get it right. An

organization’s reputation depends on what it does and does not say.

Crisis maintenance

As the crisis evolves, one can anticipate sustained media interest andscrutiny. Unexpected developments, rumors, or misinformation may

place further media demands on organization communicators. Experts,

professionals, and others not associated with the organization will

comment publicly on the issue and sometimes contradict or misinterpret

messages. Processes for tracking communication activities become

increasingly important as the workload increases.

Resolution

As the crisis resolves, there is a return to stasis, with increasedunderstanding about the crisis as complete recovery systems are put in

place. This phase is characterized by a reduction in public and media

interest. Once the crisis is resolved, a response organization may need

to respond to intense media scrutiny about how the event was handled.

In this phase, there is an opportunity to reinforce public health messages

while the issue is still current.

During the Interpandemic Period, national, state, and local health

communications professionals should focus on preparedness planning

and on building exible, sustainable communications networks. During

the Pandemic Period, they should focus on well coordinated healthcommunications to support public health interventions designed to help

limit inuenza-associated morbidity and mortality.



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Introduction

However, it is important to note that individuals will tend to simplify

complex information, attempt to force new information into previous

constructs, and cling to current beliefs (Brehm et al., 2005; Novac,

2001). Therefore, if the emergency message requires asking people

to do something that seems counterintuitive they may hesitate to act.

Because people tend not to seek out contrary evidence and are adept atmaintaining their beliefs, conicting or contrary information may be

misconstrued to conform to established beliefs (Andreasen, 1995).

Uncertainty and communication

Uncertainty exists as an extension of a situation or in the limitations of

the information and knowledge shared about that situation (Brashers,

2001). For example, as the world enters the inuenza pandemic alert

period the situation itself is ambiguous, unpredictable, and complex.

Public health experts monitoring the global situation can not know

with certainty whether a potential pandemic virus strain will becomemore easily transmitted between humans. They can not predict when

a pandemic strain will reach their region, and the decision about

who should be vaccinated rst is complicated by which virus strain

ultimately infects the population. However, uncertainty can also be

caused by existing information that is not available or is inconsistent.

Uncertainty is better or worse tolerated depending on the relevance of

the situation to the person. What is at stake?

Perception of risk

The perception of risk is also vitally important in emergency

communication. Not all risks are created equally. A wide body of

research exists on issues surrounding risk communication (Bond &

Smith, 1996; Brehm et al., 2005; Cohen, 2001), but the following

emphasizes that some risks are more accepted than others.

• Voluntary versus involuntary: Voluntary risks are more readilyaccepted than imposed risks.

• Personally controlled versus controlled by others: Riskscontrolled by the individual or community are more readilyaccepted than risks outside the individual’s or community’s

control.

• Familiar versus exotic: Familiar risks are more readilyaccepted than unfamiliar risks. Risks perceived as relatively

unknown are perceived to be greater than risks that are well

understood.



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Introduction

• Natural origin versus manmade: Risks generated by natureare better tolerated than risks generated by man or institution.

Risks caused by human action are less well tolerated than risks

generated by nature.

•

Reversible versus permanent: Reversible risk is bettertolerated than risk perceived to be irreversible.

• Statistical versus anecdotal: Statistical risks for populationsare better tolerated than risks represented by individuals. An

anecdote presented to a person or community can be more

damaging than a statistical risk of one in 10,000 presented as a

number.

• Endemic versus epidemic (catastrophic): Illnesses, injuries,and deaths spread over time at a predictable rate are better

tolerated than illnesses, injuries, and deaths grouped by time and

location (e.g., U.S. car crash deaths versus airplane crashes).

• Fairly distributed versus unfairly distributed: Risks that

do not single out a group, population, or individual are better

tolerated than risks that are perceived to be targeted.

• Generated by trusted institution versus mistrustedinstitution: Risks generated by a trusted institution are better

tolerated than risks that are generated by a mistrusted institution.

Risks generated by a mistrusted institution will be perceived asgreater than risks generated by a trusted institution.

• Adults versus children: Risks that affect adults are bettertolerated than risks that affect children.

• Understood benet versus questionable benet: Risks withwell-understood potential benet and the reduction of well-

understood harm are better tolerated than risks with little or no

perceived benet or reduction of harm.

The principles of risk communication are vital when developingmessages during an emergency. Most disaster response planners

gauge the severity of a crisis on two factors: the physical impact on

people (numbers ill, injured and dead) and property damage (dollars

and geographic areas). However, the other measure of a crisis is its

emotional toll on the people affected by the crisis. If it’s the rst

emergency of its type—manmade, imposed, or catastrophic—the

communication challenges increase.



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Introduction

How the Public Judges Messages in a Crisis

Expect the public to immediately judge the content of an ofcial

emergency message in the following way: “Was it timely? Can I trust

this source?” and “Are they being honest?” Research shows that there

are four basic elements to establishing trust and credibility: expressingempathy and caring; showing competence and expertise; remaining

honest and open; and being committed. Empathy and caring should

be expressed early in messages and repeated. Being perceived as

empathetic and caring provides greater opportunity for your message to

be received and acted upon (Sandman, 2002). In a crisis, the message

should acknowledge the fear, pain, suffering, and uncertainty being

experienced. For most public health professionals, being honest means

not being paternalistic in communication but, instead, participatory—

giving people choices and enough information to make appropriate

decisions. It means allowing the public to observe the process while

reminding them that this process is what drives the quality of theemergency response.

Empathy

The concept of empathy is critical to communicating in a crisis. Every

person has the innate ability to feel empathy. Have you ever seen a

nursery in a hospital where one baby starts to cry and within a minute

all of them are crying—that’s human empathy. We have the ability

to understand what our fellow humans are feeling even if we are not.

The challenge for a response ofcial is to believe it is appropriate toacknowledge that pain, after all we are taught to be stoic in our roles.

We must recognize that the people we want to help need us to put into

words that we understand the emotions they are feeling at the worst

moments of their lives. If we put into words what they are feeling they

will know we “get it” and they will trust us more to help them. They

may calm down enough to hear what we have to say. And then they will

be more likely to listen to our guidance.

Never say “I know how you feel” and think you have expressed

empathy. To express empathy means to put into words the actualemotion that someone is feeling. So, if someone said the words “I know

how you feel” I would be left wondering, do you really? If the person

said, “I understand how anxious you must feel waiting for an answer

about your loved one” – then I can be certain the other person has

insight about what I’m feeling because I am feeling anxious!

A national leader recently said, “Well, we want to express empathy to

the victims and their families.” That doesn’t work either. Yes, you want

Fast Facts

A pandemic may come and

go in waves, each of which

can last for 6 to 8 weeksat a time. If an inuenza

pandemic occurs, the virus

will spread easily from

person to person.

While vaccines and antiviral

medications are part of

overall pandemic response

planning, simple hygiene

habits will also be important.

Simple steps can help to

limit the spread of germs.Parents should model these

steps and teach them to their

children:

• Wash hands frequently

with soap and water (use

an alcohol-based hand

cleaner if soap and water

are unavailable);

•

Use a tissue to cover

your mouth and nose

when you cough or

sneeze;

• Use your upper sleeve if

you don’t have a tissue;

and

• Stay at home if you are

sick.(www.pandemicu.gov)



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Introduction

• The importance of strengthening community hardiness and

personal resilience to provide the optimum opportunity for

recovery from a crisis.

•

How to incorporate loss, grief and mourning rituals incommunication to the community while respecting cultural

differences.

• Distinguish which populations will be unable to receive general

public health emergency messages related to pandemic inuenza

through mass communication channels during the beginning of

an inuenza pandemic.

• Recognize the National Incident Management System and theintricacies of the Joint Information Center

• How information technology and the new media inuencecommunication decisions and pandemic preparedness.

Well-planned and well-executed crisis and emergency risk

communication, fully integrated into every stage of the pandemic

inuenza planning and response, can give the organization the

critical boost necessary to ensure that limited resources are efciently

directed where truly needed. A severe inuenza pandemic will take a

physical, emotional, and societal toll on the U.S. population. Crisis and

emergency risk communication principles will ameliorate some of the

expected negative outcomes.



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Checklist: Basic Tenets of Emergency Risk Communication

o Don’t over reassure. The objective is not to placate, but to engender, calm concern.

o Acknowledge uncertainty. Offer what you know versus what you don’t know. Show your distress and acknowledge youraudience’s distress regarding the uncertainty of the situation.

“It must be awful to hear we can’t answer that question right now . . .”

o Express that a process is in place to learn more. “We have a system (plan, process) to help us respond (nd answers, etc).”

oGive anticipatory guidance. If you are aware of future negative outcomes, let people know what to expect. Example: side effectsof antibiotics. If it’s going to be bad, tell them.

o

Be regretful, not defensive. Say “we are sorry . . .” Or “we feel terrible that . . .” when acknowledging misdeeds or failures from

the agency. Don’t use “regret,” which sounds like you’re preparing for a lawsuit.

o Acknowledge people’s fears. Don’t tell people they shouldn’t be afraid. They are and they have a right to their fears. Don’t tellthem they are idiots for their misplaced fear, acknowledge that it’s normal, human to be frightened. They aren’t experts.

o Acknowledge the shared misery. Some people will be less frightened than they are miserable, feeling hopeless and defeated.Acknowledge the misery of a catastrophic event and then help move them toward hope for the future through the actions of your

agency and actions they too can take.

o Express wishes. “I wish we knew more.” “I wish our answers were more denitive.”

oStop trying to allay panic. Panic is less common than imagined. Panic doesn’t come from bad news, but from mixed messages.If the public is faced with conicting recommendations and expert advice, they are left with no credible source to turn to for help.

That level of abandonment opens the door to charlatans and mass poor judgment. Candor protects your credibility and reduces the

possibility of panic, because your messages will ring true.

o

At some point, be willing to address the “what if” questions. These are the questions every person is thinking about and wants

to hear answers from experts. It’s often impractical to fuel “what ifs” when the crisis is contained and not likely to affect wide

numbers of people; it is reasonable to answer “what ifs” if the “what if” could happen and people need to be emotionally preparedfor it. However, if you do not answer the “what if” questions, someone with much less at risk regarding the outcome of the

response will answer them for you. If you are not prepared to address “what ifs,” you lose credibility and the opportunity to frame

the “what if” questions with reason and valid recommendations.

oGive people things to do. In an emergency, some actions communicated are directed at victims, persons exposed or personswho have the potential to be exposed. However, those who do not need to take immediate action will be engaging in “vicarious

rehearsal” regarding those recommendations and may need substitute actions of their own to ensure they do not prematurely act

on recommendations not meant for them. Simple actions in an emergency will give people back a sense of control and will help

to keep them motivated to stay tuned to what is happening (versus denial, where they refuse to acknowledge the possible danger to

themselves and others) and prepare them to take action when directed to do so. When giving them something to do, give them a

choice of actions matched to their level of concern. Give a range of responses, a minimum response, a maximum response, and a

recommended middle response

o

Ask more of people. Perhaps the most important role of the spokesperson is to ask people to bear the risk with you. People can

tolerate considerable risk, especially voluntary risk. If you acknowledge the risk, its severity, complexity and legitimate people’s

fears, you can then ask the best of them, to bear the risk during the emergency and work toward solutions. As a spokesperson,

especially one who is on the ground and at some self risk, you can model the appropriate behavior, not false bonhomie, but true

willingness to go on with life as much as possible, to make reasonable choices for yourself and your family. Don’t be glib, but

be stalwart. Your determination to see it through will help others who are looking for role models to help them face the risk too.

Americans have great heart, a sense of selessness, and a natural competitiveness. Sparking those inherent attributes will help

people cope with uncertainty, fear and misery.

Empathy, expertise, dedication and follow-through are the elements that build trust. As a spokesperson, you need to quickly

build trust and credibility if you hope to have your public health recommendations acted on by the public.



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Checklist: Scientic Risk Communication for the Public

Success depends on the interaction of the following factors: pre-existing trust and credibility of the presenting

organization; level of foreknowledge in the target audience; message development and spokesperson’s presentation;

seriousness or relevance of the information to the target audience; competing points of view (adversaries); and follow-up.

Organization’s Reputation

o Different publics trust different information sources

o 48% of Americans trust CDC as a source for reliable information

o Perceived competence is a key factor in public’s trust to ofcial responses

o Equitable treatment despite ethnicity or income is vital

o

American’s trust their own doctor most for health information (77%) but also trust local health dept. (61%) and

local hospital (53%)

o High-prole events of the past are most likely to form public’s opinion of the organization

Target Audience Expertise/Psychology

o

People act on the information they have, even if it is incorrecto People take more precautions when they feel threatened or are concerned

o People act rationally to protect themselves, families, and pets

o Beware of stigmatization against products, animals, population groups, and nations

o Find out what the audience knows now and what level of information they want (long-term health issues require

more information; short-term crisis health issues require less information and more denitive conclusions)

o Denial is alive and well (threat must be real, imminent, and actionable)

o Understand audience by age/culture/level of experience or familiarity with the subject/language/geographic

location

Message Development

o

“Alarm” of the day? Be judicious in attempting to educate about risk

o

Controversial decisions based on technical data/science must be explained

o Action by public should be voluntary with police power a last resort

o

Use third-party validations when possible (consistent message from multiple sources)

o Association, causation, risk factors, adverse risk, relative risk, theoretical risk, etc., all mean something different

to scientists but do not to the media/public

o Messages that challenge audience beliefs will be resisted

o Theoretical risks are more distressing than risks stated in whole numbers

o Statistics perceived as manipulated or convoluted will not be trusted

o

Anecdotes, scenarios and examples are best ways to teach about risk

o

Be careful about risk comparisons whose attributes are not similar (e.g., number of vehicle crashes in three weeksin D.C. versus number of sniper shootings).

o Present: short, concise, focused messages, then repeat the message consistently, and give positive action steps

whenever possible

o

Eliminate jargon

o Eliminate scientic terms unless they are absolutely vital and can be dened at a level of understanding of a

young adolescent.



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Introduction

Spokesperson (Working through the media)

o The scientist’s language and the public/media’s language are different

o Scientists use qualiers—media (public) want bottomline (in or out, dangerous or safe).

o Scientists want full explanation—media want highlights and conclusions

o Scientists attempt to avoid controversy—media want controversy and will focus on negative

o

Scientists want data to be released when it’s “seasoned”—the media/public want fresh data NOW.o

Spokespersons are judged on message and delivery

o Spokespersons build credibility with empathy, competence (ability to share expert knowledge), honesty, openness

and commitment

o Tell the truth, always

Al l Risks Are Not Equalo

The public hates uncertainty

o The public hates not being in control of their well-being and that of their family, and pets.

o

Socio-economic impacts can skew public reaction (e.g., my livelihood depends on the recreational park remainingopen so Eastern Equine Encephalitis in the community may not be a reason to close operations to conduct control

measures like aerial spraying for mosquitoes.)

o Types of risks more and less tolerated by the public:

o Voluntary versus involuntary

o Controlled by self or controlled by others

o Familiar or exotic? (u verusus SARS)

o Natural origin or manmade (Earthquake versus business or criminal)

o Reversible or permanent (Broken leg versus severed leg)

o

Statistical or anecdotal (1 in 10,000 die from anesthesia versus Aunt Mae died from anesthesia)

o Endemic (spread over time) or epidemic (catastrophic) (car crashes versus plane crash)

o

Fairly distributed or unfairly distributed (tornado deaths versus terrorist bombing)

o Generated by trusted institution or mistrusted institution

Media Advocacy Groups or Competitors

o Is litigation a possibility? Then, public reactions may not be consistent with the ofcial assessment of the risk

o

Is it opinion or scientically based information being provided?

o Be careful to correct message but not disparage the source if the source is accepted by target audience

o Don’t expect logic and reason arguments to outweigh emotional or common sense messages

Follow-up: Monitoring, Adjusting, and Commitment

o

Environmental scanning needed to quickly nd out if public is: misunderstanding, believing rumors, or spreadingmyths (Internet is hotbed for these).

o

Media and public hotline calls should be assessed for trends

o New concerns should be addressed quickly

o

Public access to additional information and personal consultation is best



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Introduction

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What is Different

Severe Inuenza Pandemic:

What is Different?

˘ ˘dif•fer•ent (dif´ r- nt, dif´r nt)adj.

1. Unlike in form, quality, amount, or nature; dissimilar: took different approaches to the problem.

2. Distinct or separate: That’s a different issue altogether.

3. Various or assorted: interviewed different members of the community.

4. Differing from all other; unusual: a different point of view.

Which killed more people, World War I or the 1918 inuenza

pandemic? World War I claimed an estimated 16 million lives. The

inuenza pandemic that swept the world in 1918 killed an estimated50 million people. One fth of the world’s population was attacked

by this deadly virus. Within months, it had killed more people than

any other illness in recorded history.

The [outbreak] emerged in two phases. In late spring of 1918,

the rst phase, known as the “three-day fever,” appeared without

warning. Few deaths were reported. Victims recovered after a few

days. When the disease surfaced again that fall, it was far more

severe. Scientists, doctors, and health ofcials could not identify

this disease which was striking so fast and so viciously, eluding

treatment and defying control. Some victims died within hours of

their rst symptoms. Others succumbed after a few days; theirlungs lled with uid and they suffocated to death.

The [virus] did not discriminate. It was rampant in urban and rural

areas, from the densely populated East coast to the remotest

parts of Alaska. Young adults, usually unaffected by these types of

infectious diseases, were among the hardest hit groups along with

the elderly and young children. The u aficted over 25 percent of

the U.S. population. In one year, the average life expectancy in the

United States dropped by 12 `years. It is an oddity of history that

the inuenza epidemic of 1918 has been overlooked in the teaching

of American history.

(National Archives: Online Exhibit: The Deadly Virus: The Inuenza

Epidemic of 1918. Available from http://www.archives.gov/exhibits/

inuenza-epidemic/index.html.)

.

We are the descendants of the survivors of the 1918 inuenza pandemic.

Historians, like those at the National Archives, believe it’s an oddity

that so little has been written about this worldwide killer. Only since

the re-emergence of the avian inuenza H5N1 virus in this decade has

Objectives:

•

Appraise the range of

challenges presented

by a severe inuenza

pandemic and the

communication steps

that could be taken.

• Formulatecommunication

priorities based on a

full exploration of thecontext of a severe

inuenza pandemic.

• Recognizecommunication themes

required to fulll severe

inuenza pandemic

response goals of fewer

disease cases, spread

over a longer timeframewith fewer deaths.



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What is Different

so much attention been paid to that enormous public health tragedy.

It was the very voraciousness of this virus that condemned it to the

dusty archives in the rst place. It swept the globe and crowded the

graveyards. The world, post-1918, had no need to give witness to

this affront to the human race. After all, it was an absolute, shared

experience. Who didn’t know about “the 1918 plague?” It has takennearly a century and a new inuenza threat to emerge to make us now

look both backward and forward with renewed interest. The public

health question is: “In a severe inuenza pandemic what is different?”

A pandemic is a global disease outbreak. Inuenza pandemics occur

when a new inuenza A virus emerges for which there is little or no

immunity in the human population, begins to cause serious illness and

then spreads easily from person-to-person worldwide. This makes it

a dreaded disease, even in this era of advanced medical technology.

Historically, the 20th century saw 3 pandemics of inuenza:

• The 1918 inuenza pandemic caused at least 675,000 U.S.

deaths and up to 50 million deaths worldwide

• The 1957 inuenza pandemic caused at least 70,000 U.S. deathsand 1-2 million deaths worldwide

• The 1968 inuenza pandemic caused about 34,000 U.S. deathsand 700,000 deaths worldwide.

Inuenza viruses do not respect distinctions of race, sex, age, profession

or nationality, and are not constrained by geographic boundaries.

The next inuenza pandemic is likely to come in waves, each lasting

months, and pass through communities of all sizes across the nation

and world. While a pandemic will not damage power lines, banks or

computer networks, it will ultimately threaten all critical infrastructure

by felling ill essential personnel from the workplace for weeks or

months.

This makes a pandemic a unique circumstance necessitating a strategy

that extends well beyond health and medical boundaries, to include

sustaining critical infrastructures, private business in all sectors, themovement of goods and services across the nation and the globe,

and economic and security considerations. The National Strategy for

Pandemic Inuenza (White House, 2005) guides our preparedness and

response to an inuenza pandemic, with the goal of:

1) stopping, slowing or otherwise limiting the spread of a pandemic

to the United States;



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What is Different

2) limiting the domestic spread of a pandemic, and mitigating

disease, suffering and death; and

3) sustaining infrastructure and mitigating impact to the economy

and the functioning of society.

A pandemic will require planning, preparedness, and action on the

part of many individuals, institutions, and industries not accustomed

to responding to health crises. The Department of Health and Human

Services (HHS) Secretary, Mike Leavitt, stated that “communication

is the heart of our planning” for a pandemic (www.pandemicu.gov,

2006). We must work to ensure there is clear, effective and coordinated

risk communication, domestically and internationally, before and

during a pandemic. This includes identifying credible spokespersons

at all levels of government to effectively coordinate and communicate

helpful, informative messages in a timely manner. We must also

communicate to individuals, in the pre-pandemic period, infectioncontrol behaviors and the specic actions they will need to take during

a pandemic, such as self-isolation and protection of others if they—

themselves contract inuenza.

Understanding what an inuenza pandemic is, what needs to be done

at all levels to prepare for a pandemic, and what could happen during a

pandemic, helps us make informed decisions, both as individuals and as

a nation. Should a pandemic occur, the public must be able to depend on

its government to provide scientically sound public health information

quickly, openly and consistently.

While the basic tenets of Crisis and Emergency Risk Communication

(CERC) fully apply to pandemic inuenza (Reynolds, Galdo, Sokler,

2002; Reynolds, 2004; Reynolds & Seeger, 2005), the very magnitude

of this impending challenge requires communication professionals to

delve deeper. What will be different in a severe pandemic and what

specic CERC activities should be intensied?

Challenges from a severe inuenza pandemic will wreak havoc on us,

our communities, nation, and the world at the biological, psychological/

spiritual, and sociological levels. Communication professionals must begin to meet these challenges, where they can, with available tools

and research. Biological, psychological and sociological challenges

will not affect all individuals or communities equally and may become

more or less critical in time as preparedness strides are made (e.g.,

breakthroughs in vaccine development). However, our communication

planning and activities should consider each of these challenges. For

the purposes of this communication planning, the assumption is that we

must prepare to respond to a severe pandemic. To prepare for anything

less would be folly.

Challenges from a

severe inuenza

pandemic will wreak

havoc on us at the

biological, psychological

and sociological levels.



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What is Different

Few other natural risks

so equally threaten the

entire world.

Biological Challenges

Little or no immunity worldwide

When a pandemic inuenza virus emerges, its global spread is

considered inevitable. Death rates for a severe pandemic will behigh and largely determined by four factors: the number of people

who become infected; the virulence of the virus; the underlying

characteristics and vulnerability of affected populations; and the

effectiveness of preventive measures.

Preparedness activities should assume that the entire world population

is susceptible. Most people alive today have not lived through a threat

similar to that posed by severe inuenza pandemic. Humans are adept

at engaging their psychological defense mechanisms to avoid thinking

about risks. They do so when they speed down the interstate to workor indulge in a banana split though they have high cholesterol and

diabetes. Denial allows us to continue to function in a risky world. Even

so, few other natural risks so equally threaten the entire human race

with the stark possibility of widespread death within a few short weeks

as does a severe inuenza pandemic. Countries might, through measures

such as border closures and travel restrictions, delay arrival of the virus,

but they cannot stop it. Therefore, we must take steps to prepare as

individuals, as families, as communities, and as a nation.

When a threat is not seriously looming, however, only a quarter of the

U.S. population will engage in efforts to prepare for an emergency(American Red Cross, unpublished data, 2005). People ready to prepare

expect guidance from responsible organizations now. We must make

every effort to reach those interested citizens with the best, most

accurate, and useful information to help them prepare. They will expect

clear action items.

A modest portion of the 75% of the population not engaged in

preparedness efforts will be interested in information about the threat,

but will not take any action to prepare early. The majority of the

population will have little interest—that is, until the threat seems real.

Threats become real to different people at different times. Unfortunately

for some, the threat will not become real until it is too late. For the

“just-in-time” preparers, it will be important that they know where to

get life-saving information quickly. Much of the early preparedness

public outreach should build awareness about who can give them

credible information when they want it and where. The government

website, PandemicFlu.gov (available day and night around the world



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What is Different

and updated regularly), is an example of such a tool. The national

website, supplemented by local sources of information, should be

widely advertised and reinforced in all messaging.

Ideally disaster response ofcials would prefer to have everyone well

prepared in advance of a pandemic. Despite our best efforts, that isnot likely to happen. Instead, we must engage the “early preparers”

and ask them to help when the “just-in-time” preparers feel the threat

is real. The “early preparers” may be the neighborhood leaders, or

the rst person to bring a preparedness checklist to their workplace,

their church, or their children’s schools. Research following Hurricane

Katrina reinforces that women are more likely to prepare for disasters

than men (Seeger, 2006). Accordingly, women should be a focus of

preparedness communication outreach.

More persons are high risk

More than 90 million people in the United States live with chronic

illness. More than 36 million people in the United States are 65 years

of age or older. People with chronic illness, suppressed immune

systems, older adults, pregnant women and young children are at

greater risk of serious illness, complications, and death from seasonal

inuenza, and will presumably be so from a pandemic inuenza virus

as well. Although no one can be certain which subpopulations will be

hardest hit, those who are already vulnerable because of current health

conditions or age may feel emotionally vulnerable. They may need

special guidance on how they can protect themselves.

Communication activities before a pandemic should include outreach

to these populations through health associations and in health-care

settings. Concerned family members or caregivers should also be

alerted to any special concerns for these populations and directed to

guiding information. People who are traditionally targeted to receive

seasonal inuenza vaccine may not understand and may even feel

abandoned if they do not receive the vaccine early in the pandemic. The

potential for mixed messages that confuse the public is high if seasonal

inuenza occurs at the same time the nation is being urged to prepare

for pandemic inuenza. Messages must be delivered scrupulously toalways make the distinction between seasonal and pandemic inuenza.

Populations at higher risk from seasonal inuenza must continue

to be the focus of outreach because of their potential and perceived

vulnerability to pandemic inuenza.

Disaster response

ofcials would prefer to

have everyone to be well

prepared in advance of

a pandemic. Despite our

best efforts, that is not

likely to happen.



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What is Different

It is very different to tell

a grandmother and her

grandchildren that she

is not getting the early

vaccine for pandemic u.

When a pandemic inuenza vaccine becomes available, communicators

should take time to explain who will receive the earliest doses of

vaccine, especially if these groups differ from those who are typically

recommended to receive seasonal u vaccine earliest. It is logical to

determine that older persons, for example, should not be rst in line

for the earliest vaccine during a u pandemic, in order to vaccinate lawenforcement and health care workers so that they can stay on the job.

However, it is very difcult to tell a grandmother and her grandchildren

that she is not getting the early vaccine for pandemic u as she does

during seasonal inuenza outbreaks.

Communication messages will have to make both logical and

emotional appeals for understanding. Societal-level decisions that put

the greater good for the greater number rst can still be a hard pill

to swallow. Community role models (i.e., well-known people with

similar characteristics to those who do not receive the vaccine earlier)

could publicly express their willingness to step back, at some risk tothemselves, so the community will fare better. Any personal sacrice

made by people adhering to public health recommendations should be

acknowledged and reinforced through expressions of thanks. Anything

less will engender resentment, a sense of privilege for some, and

possible non-adherence to further public health and infection control

guidelines for pandemic inuenza.

Evolves in waves

Perhaps the most daunting aspect of pandemic inuenza is that itwill likely occur in two or three waves of 6 to 8 weeks duration in a

community over about an 18-month timeframe. Until the pandemic

unfolds, one can not predict which wave could be most severe, strictly

from the biological nature of the virus, or how it does or does not

mutate between waves. Facing the virus during the rst wave will be a

traumatic experience for a community. Knowing that it will be cycling

around a second or third time could be severly demoralizing.

Although it may seen counterintuitive, people should be given even

the very worst news about what they are facing as quickly as possible

without softening the news. Soft-pedaling what could be the worst eventof their lives won’t increase the credibility of response organizations

in the long run. Most people will use the information to adapt their

environments and engage coping strategies. The fact that the virus

will burn through a community more than once should be made clear

before the pandemic begins. Information should focus on community

cooperation and personal resilience. As the pandemic begins, continued

emphasis on the importance of community measures before, during,



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What is Different

and after each wave may mitigate the impact of the rst and subsequent

waves. Acknowledge shared misery and point people in the direction of

things they can do to control their situation.

Psychological/Spiritual Challenges

Uncertainty

Planning for a severe pandemic is fraught with uncertainty: when will

it happen, where will it begin, who will be at greatest risk of death, will

vaccines work, will they get to us in time, will antivirals work, will

there be enough, how will I care for my kids if schools close, what if

we put effort into this and the threat from H5N1 fades, what would I do

if I couldn’t drive my taxi or open my restaurant, will people help each

other or take advantage of each other, are we emotionally prepared for

death at this magnitude?

Uncertainty exists as an extension of a situation or in the limitations of

information and knowledge shared about that situation (Brashers, 2001).

As the world remains in the third stage of the inuenza pandemic alert

period, the situation is ambiguous, unpredictable, and complex. Public

health experts monitoring the global situation can not and do not know

with certainty whether, or if, the H5N1 inuenza strain will become

more easily transmitted between humans, or which inuenza A strain

has the potential to become a pandemic virus strain. The development of

a pandemic inuenza vaccine, as well as decisions regarding who gets

the vaccine and when, is dependent on which strain of the virus adaptsto t pandemic qualications. Neither can public health experts predict

when a pandemic strain will reach the United States. Uncertainty can

also be caused by inconsistent information or information not available

to individuals. Therefore, health ofcials should rapidly share what they

know when they know it to reduce the anxiety of uncertainty.

Uncertainty can be related to the probability of something occurring:

uncertainty is at its highest when all outcomes are equally likely.

Uncertainty, however, is not only a function of assessing probabilities;

uncertainty management occurs within a context of self-efcacy, value

judgments, and assessments of intention. Uncertainty is better or worse

tolerated, depending on the relevance of the situation to the person, and

how one determines what is at stake.

Uncertainty can increase anxiety if there is a perception of danger or

threat (Brashers, 2001). To reduce anxiety, people engage in information

gathering and processing to look for options and conrm or disconrm

their beliefs. The information used in this process does not have to be

accurate. To improve coherence and reduce anxiety, persons may be



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What is Different

Individuals can manage

stress at a level that will

reduce hopelessness

and helplessness.

selective about the information they attune to in attempting to reduce

uncertainty. They may discount information that is distressing or

overwhelming. People who seek information to reduce anxiety from

dangerous uncertainty may choose a familiar source of information over

a less familiar source, regardless of accuracy, and may be more attentive

to behaviors and language styles of persons in power (Brashers, 2001).Persons less certain of their ability to process information involving

complex situations may choose an advocate to collect and interpret

information for them.

Response organizations and communication professionals should

attempt to reduce uncertainty when and where they can. A fair message

in the earlier phases of pandemic alert is to simply acknowledge the

uncertainty. One must also be prepared to answer “What if” questions.

This is how people begin to manage their anxiety. Asking “what if all

the caskets are used up in town?” is a legitimate question for someone

who is processing the threat on a community or personal level. Anyreply to that question that discounts this type of thinking or laughs at the

questioner will quash personal preparedness efforts.

The greatest uncertainty for communities and individuals occur in the

earliest phases of a pandemic. At that time, messages should include

their questions, explain why the answer is not available and commit to

a process to try and answer their questions. If response ofcials do not,

someone else will answer the question and it may be someone who is

not invested in a positive outcome for the community.

Community hardiness and personal resilience

The public must feel empowered to take action in the event of a crisis to

reduce the likelihood of extreme stress, victimization and fear (Tierney,

2003). Physical and mental preparation will relieve anxiety despite

the expectation of potential injury or death. An “action message” can

imbue people with the feeling that they can improve a situation and not

become passive victims of threat. By giving persons who are stressed

a restored sense of control, individuals can manage stress at a level

that will reduce hopelessness and helplessness. Altering self-talk and

offering helping tasks can be important during the recovery phase of asevere pandemic.

Community hardiness depends on community cohesion. Nonetheless,

conict is inevitable in a group (Zastrow, 2001). The degree of task

conict and relationship conict in a group depends on the level of

trust among group members. Task conict (e.g., disagreement about

how to determine which social events should be cancelled) can add to

cohesiveness and improve the performance of the group. In contrast,



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What is Different

relationship conict (e.g., the mayor acts disdainfully toward the

community activist who may join the mayoral race against him next

year) is disruptive to group achievement. Relationship conict in a

low-trust group causes biased information processing, self-fullling

prophecies, and personal attacks. As trust grows, relationship conicts

are moderated and tasks can be accomplished. Conict in a group can be addressed through role reversal, empathy, inquiry, “I”-statements,

disarming, positive reinforcement, and mediation (Zastrow, 2001).

However, these communication strategies for handling intragroup

conict are appropriate only when time is not a factor. When time for

settling group conict is constrained, such as in the beginning of a

pandemic inuenza wave, prosocial behaviors such as helping others

and expressing empathy increase community or group cohesiveness.

Communication messages surrounding preparedness and response to a

severe pandemic should acknowledge different emotions that may arise

among the community in addition to stressing the importance of helpingothers. Likewise, refocusing individuals and groups on the task to be

accomplished can reduce harmful conict.

Number of deaths out of time

About 2.5 million people die in the United States each year. In a severe

pandemic, an estimated 2 million people in the Unites States could die

from inuenza and its complications, in a span of 18 months (HHS,

2006). This 2 million is in addition to the annual rate. If children

and young adults die in high numbers during a severe pandemic, thechallenge to grief recovery will be great. These “deaths out of time”

are unnatural, hence, the grief process will be challenging. If accepted

bereavement rituals are ignored or cut short through necessity, (i.e. due

to recommendations limiting social interaction) the emotional toll could

be even greater.

Communication activities before a pandemic should focus on

understanding community bereavement norms to ensure that messages

during the pandemic are respectful of those norms. No message can

prepare a community for the magnitude of deaths over a short period.

However, messages being developed now, that discuss the course ofthe disease and proper handling of bodies, should be sensitive in tone.

What is now an intellectual exercise will not be when people are dying,

especially people in your own community. A clinical tone is appropriate,

but be sensitive to how people will react to what they are reading and

avoid sensational descriptions.

If children and young

adults die in high

numbers during a severe

pandemic, the challenge

to grief recovery will be

great.



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What is Different

When deaths occur, acknowledge loss and help redirect people to

coping tasks—give people things to do to contribute to the community

and family well-being. Encourage symbols of mourning, but remember,

community memorial services should be held only once the outbreak is

over.

Sociological Challenges

Behaviors of others impact infection rates

When an infectious disease is transmitted easily from person to person,

the behaviors of others can either protect or threaten your health. When

people are dependent on each other’s behavior for their very lives, the

potential for conict is present. Established public health messages

related to infectious disease prevention may diffuse disagreement

regarding preventive measures, as they already stress handwashing,cough etiquette, and staying home from work or school if ill.

During a severe pandemic, public health measures to reduce the spread

of disease may also include well household members staying home

when any member of the family is ill with inuenza, school or business

closings, or limiting group gatherings. As the cost (e.g., loss of social

contact or esteem, pay and prot) of a behavior increases, it may be

more difcult for people to take recommended actions, even at the risk

of severe illness or death. Some people will engage in denial (e.g., it

won’t happen to me) and refuse to alter their behaviors. Individuals

with high-risk, high-adventure personalities will also not alter their behaviors (e.g., sneezing on each other is Russian roulette). Some will

expect the burden of the mitigation measures to be borne by others, not

themselves, and will not alter their behaviors (e.g., somebody should do

it to protect us, but I’m too busy/important to be bothered). Some will

be very concerned about the risk but will believe that they can’t alter

their behaviors (e.g., if I don’t get in my taxi even though I’m sick, I

won’t be able to put food on the table). While community mitigation

activities to slow the spread of pandemic inuenza will not need 100%

cooperation, communication messages must be directed at everyone.

Social and community norms may be challenged. People in the United

States have a strong work ethic, with a concomitant belief that one

should “tough it out” and come to work when ill. In a severe pandemic,

that might be true if you sprained your ankle rollerblading over the

weekend, but not true if you have fever, muscle aches, and the start

of a cough. People will need permission to go against societal norms

that could hurt them during a pandemic; they will need to hear from

people who inuence them that they are taking the right step by staying



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What is Different

home. Formal and informal messaging, including public service

announcements, should reinforce this. Of course, barriers to adherence

generated by something other than cultural dissonance could prevent

people from taking a life-saving action. These must also be addressed

and communicated (e.g., adjustments to sick-leave policies).

Communication messages before a pandemic must help people

understand disease transmission and the reasonableness of

recommended actions, and stress personal responsibility. These

messages should also acknowledge the “cost” to the individual or

industry. Community pressure to conform to life-saving behaviors can

also be effective. When a pandemic strikes and community mitigation

activities begin, communicators must praise adherence and pass along

solutions to people who want to comply but believe they can not.

Early inadequate vaccines/antiv irals

For the majority of the population, a severe pandemic will be met with

no or little vaccine, especially during the rst wave. The same will be

true for antivirals. There is no communication task more difcult than

telling people that there’s a “x” to a problem but they will not receive

it now nor possibly ever. This prospect is so daunting that any misstep

in communication and execution could create an atmosphere necessary

for chaos.

There are, however, some primary steps that should be taken to avoid

this possibility:

• Involve community members in discussing realities of a severeu pandemic. However, what sounds fair in early pandemic alert

phases, absent a threat, may not sound so fair when the threat

presents itself. Be aware that points of view can and will change.

• Ensure that early messages stress the realities of limitedresources. However, do not refer to persons who receive

antivirals/vaccines rst as “priority or essential groups.” (In

early formative research efforts, these were “loaded” words

among the public.)

• Be transparent. Before being asked, ensure that the criteria used

for deciding who will need the rst supplies are available to

the public. Explain that some people are at greater risk because

they are caring for sick persons or critical to the socioeconomic

infrastructure of the community because they keep the city

water pumping. Show the value of the allocation criteria to the

community as a whole.



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What is Different

• Account for vaccines and antivirals publicly – tell thecommunity who is receiving them.

• Do not change established vaccine or antiviral allocation

guidelines without rst telling the community that you are

adjusting the supplies based on new information/criteria.

• Be certain to avoid any hint of privilege or favoritism related toallocation. (Be prepared to be accused of both—respond with

empathy and facts.)

• Help people who won’t be getting vaccine by telling them

interim steps they can take to avoid illness.

Openness, empathy, and consistency will be critical. Tell people all you

know as soon as possible, acknowledge fear, anxiety, and helplessness,

and don’t alter messages unnecessarily. Appeal to individuals’ sense of

fairness and

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